GW1-2022-02992_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD QW-1) For .Internal use Only:
1.Well Contractor Information:
���1 +t[✓� 14.WATER ZONES
Well CoohactotNatne FROM TO DBSCREMON
&
xc we I Ckynhwtor Cceascathmxun,I,@
W. � t e&4 ZJ�S �tir�ll FROM To r 10030 DIAMS-cam Wells) ea
r6R TffiCRtVBss MAA1aRIAi.
Company Name F2 m- RI/Z—.
16.EMMIM CAS@IG OR TUBING dosed-1
2.Wen Construction Permit : FRoM 'M I DIAMEM I MHCMMM IMATt3RiAL
List all applicable well conouctlon permits(l.e.UIC,Coway.State,Variance,etc.) ft. ft. iIL
3.Well Use(checkwell use): % ft. in.
water Supply Well: 17:SCREEN
FrMM 1aO D S7d7MM MATERUL
Agricultural E}MunicrpaMblic 0 ft. R. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) M R. im
Industrial/Commerchai Residential Water Supply(shared) M GROUT E
hri tine FROM To MATERIAL EMPLACEMEIVT40DOtW
Non-Water Supply Well: R' (® R' "H 1
Monitoring ecovery M tt.
ection Well: it. M Aquifer Recharge �GroundwaterRemediation19.SJ%M VBLi►i►CKAquifer Storage and Recovery Salinity Barrier FROM To mATSRIAL sMulpt
Aquifer Test DStomuwater Drainage h- n•
Experimental Technology 1ISubsidence Control & ft.
Geothermal(Closed Loop) Tracer 20.DRELUNG,LOG attach additional shy ff
Geothermal Coolie Return Other(explain under#21 Ramada FROM To DBSCRI MON co =Wreck
ft.
4.Date Well(s)Completed: �6`Z?r- Well M#- Z 12_ ft. tt.
Sa.Well Location: 8. R. -14
ft
���� . ft.
Err i_. 41t71.,r� l t aFe . s.�M1
Facility/OwnerName T-- Faci ty ID#(if applicable) R• &
MAP A 9 it
I f a �- � fL ft.
Physical)Address.alyl,and Tap ft. ft• E
go l at.R6MARl. . I}j,. .alt^ .,?.� •,vim e r .
County Parcel IdentificationNo.(1?M
3b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sui5clent) 22.Certification:
3402 2-,65-09 N '79ALIg 'l q.,3!r93G"
6.1s(are)the wen(s)Qfl(ermanent or 13Temporary r ofCerti6ed Well Co r Date
�� 4 signing this form.I herby certify that the well(s)was(were)conumcied in ammaw ae
7.Is this a repair to an eft well: Dyes or D(o with ISANCAC 02C.0100 or1SANCAC 02C MOO Well Construction SWndw*and that
If this is a repair,full out iaowrt well constracdon igjormation and explain the naaua of the ropy of ft record has been provided to the well owner.
repair under#21 remarAtssaulon or on the back of this form. 23.Site diagram or additional well detail
S.For Geopraobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of walls construction details..You may also attach additional pages if necessary.
drilled: S31�M1TTAL 7SVSTRIICTIONS
9.Total well depth below land surface: r (ft.) 24a.For All Wells: Submit`this Rem within 30 days of completion of well
For multiple wells list all depths if dif ferent(ewmple-3@200'and 2@100)
construction to the following:
10.Static water level below top of casing: 5 (ft:) Division of Water Resources,Information Processing Unit,
If water level is above casing,use//"+" 1617 Mail 3ervi i Center,Rale%b,NC 27699-1617
U.Borehole diameter. to-Vg (in.) 24b.kbr Inieeftm Wells t In addition to sending the form to the address in 24a
12.Well construction method: Zo 1 _ _�J above,also submit one copy of this form within 30 days of completion of well
(Le.anger;�+y,cable,ducapush,do) �-L( f construction t0 the f0110wir1g j
FOR WATER SUPPLY WELLS ONLY: Division of Water Resource,Underground bdection Control program,
1636 Mail Service Center,Raldo,NC 276WI636
13a.Yield(gpm) Method of test: 8/0"ji-V20,44Cgormater supply&Iniection Wells: In addition to sending the form to
the addmss(es) above, also submit one copy of this form within 30 days of
13b.Disinfecdon tape: 1''/ Amount" c%.r, completion of well construction to the crnmty health department of the county
where consttucled.
FormGW-1 NmthCuobnaDeWmmtofFavimnmeatdQoaCity-DmmonofWamr" Revised2-222016